Genetic/Genomic Test denials: 51.7% overturned by independent reviewers
In 582 California IMR decisions from 2018 to 2026, reviewers overturned the plan 301 times (51.7%). In the last five years: 52.9% of 314. Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Cancer | 328 | 49.1% | 55.3% of 190 |
| Genetic Diseases | 32 | 62.5% | 66.7% of 15 |
| Pregnancy/Childbirth | 31 | 48.4% | 33.3% of 12 |
| Cardiac/Circ Problem | 24 | 58.3% | 60.0% of 15 |
| Mental Disorder | 21 | 9.5% | 0.0% of 12 |
| Prevention/Good Hlth | 19 | 42.1% | 50.0% of 8 |
| GU/ Kidney Disorder | 19 | 26.3% | 23.1% of 13 |
| OB-GYN/ Pregnancy | 17 | 94.1% | — |
| Endocrine/Metabolic | 13 | 53.8% | 50.0% of 6 |
| CNS/ Neuromusc Dis | 12 | 83.3% | 66.7% of 6 |
| Pediatrics | 11 | 81.8% | 66.7% of 6 |
| Blood Related Disord | 11 | 81.8% | 71.4% of 7 |
| Autism Spectrum | 10 | 70.0% | 83.3% of 6 |
| Digestive System/ GI | 8 | 37.5% | 50.0% of 2 |
| Skin Disorders | 7 | 42.9% | 50.0% of 6 |
| Immuno Disorders | 6 | 33.3% | 33.3% of 3 |
| Ears/Nose/Throat | 5 | 80.0% | 100.0% of 2 |
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 46 | 56.5% |
| 2022 | 83 | 41.0% |
| 2023 | 91 | 61.5% |
| 2024 | 51 | 52.9% |
| 2025 | 42 | 54.8% |
| 2026 | 1 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 170 | 44.1% | 51.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 135 | 51.9% | 51.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 27 | 11.1% | 51.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 13 | 69.2% | 51.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 12 | 25.0% | 51.7% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 6 | 83.3% | 51.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 16.7% | 51.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that a patient has requested reimbursement for a Guardant360 blood test. Mutational testing, including blood-based next generation sequencing, is recommended in the National Comprehensive Cancer Network (NCCN) guidelines. The Guardant test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. According to the NCCN guidelines on melanoma, molecular testing …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for Natera Renasight genetic panel test. If caught early, medical management for autosomal dominant polycystic kidney disease (ADPKD) is altered to optimize blood pressure, monitor kidney functioning more frequently, and to monitor for other organ involvement. Gene testing is indicated to establish or confirm the …”
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for Baylor Trio Whole Genome Sequencing (WGS). WGS is the most extensive and high-yield genetic testing to date, with multiple studies demonstrating its vast power to identify disease-associated genetic variants across a diverse spectrum of human diseases directly affecting treatment. Per the …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Genetic/Genomic Test denials overturned?
In 582 California IMR decisions from 2018 to 2026, reviewers overturned the plan 301 times (51.7%). In the last five years: 52.9% of 314.
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.